CNA Certification (Written Exam)Basic Nursing SkillsHard
While assisting a resident with morning care, a nurse aide notices the resident's lips and fingertips have a bluish tint and the resident is having difficulty breathing. What should the nurse aide do first?
- AImmediately report the finding to the nurse
- BDocument the observation in the chart at the end of the shift
- CIncrease the resident's oxygen flow rate without consulting anyone
- DWait to see if the color improves before taking any action
Show answer & explanationAnswer & explanation
Correct answer: A. Immediately report the finding to the nurse
Bluish discoloration of the lips and fingertips (cyanosis) combined with difficulty breathing indicates a possible oxygenation emergency and must be reported to the nurse immediately, as this can be life-threatening.
Why the other options are wrong
- B. Delaying documentation until end of shift could allow a serious condition to go untreated.
- C. Nurse aides cannot adjust oxygen settings; that requires a licensed provider's order.
- D. Waiting to see if it improves risks delaying critical intervention for a potentially life-threatening problem.
Reporting Cyanosis
Cyanosis (bluish discoloration of lips/skin) with breathing difficulty is an emergency sign that must be reported to the nurse immediately.
- Cyanosis indicates low oxygen levels in the blood
- Nurse aides report abnormal findings right away, they do not diagnose or treat
- Never adjust oxygen equipment without a nurse's direction
Memory trick: 'Blue lips, breathe fast — report don't wait'